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1
Michael A. TynanPublic Health AnalystCenters for Disease Control & Prevention Office on Smoking and Health
Ending the Tobacco Use Epidemic
The findings and conclusions in this presentation are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Strategic Alliance for Health, Action InstituteHouston, TXApril 27, 2010
22
About 443,000 U.S. Deaths Per Year Attributable to Cigarette Smoking
*Average number of deaths, 2000-2004.
Source: Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses --- United States, 2000—2004 MMWR 2008;57(45):1226-1228.
Other cancers35,500
Chronic ObstructivePulmonary
Disease92,900
Lung cancer128,900
Stroke15,900
Other diagnoses44,000
Ischemic Heart Disease126,000
Every year:$96 billion in medical costs$97 billion in lost productivity
3
Smoking and Secondhand Smoke Damages the Entire Human Body
Image: ImpacTeen Chartbook: Cigarette Smoking Prevalence and Polices in the 50 States.Sources: Surgeon General’s Report, 2004, 2006.
Smoking Secondhand Smoke
44
Trends in Current Cigarette Smoking by High School Students and Adults—United States, 1965-2007
Youth HP 2010 - 16%
Adults HP 2010 - 12%
0
5
10
15
20
25
30
35
40
45
1965 1968 1971 1974 1977 1980 1983 1986 1989 1992 1995 1998 2001 2004 2007 2010
Year
Pe
rce
nt
*High school students who smoked on 1 >/ of the 30 days preceding the survey--United States, CDC. Youth Risk Behavior Survey, 1991-2007.
** Total population adults who were current cigarette smokers, National Health Interview Surveys, 1965-2006.
High school students*
Adults**
5
Age-adjusted smoking rates
9.2 - 16.4
16.5 – 17.6
17.7 – 19.4
19.5 – 21.7
22.2 – 26.6
Note: Persons who have smoked at least 100 cigarettes in lifetime and currently report smoking everyday or some days. SOURCE: Behavioral Risk Factor Surveillance Survey, NCCDPHP, CDC.
Cigarette Smoking in the U.S., Adults 18 Years and Over, 2008
6Source: CDC Division of Heart Disease and Stroke Prevention
Heart Disease Death Rates, U.S. 2000-2004
77
Evidence-Based Interventions
Sustained funding of comprehensive programs
Excise tax increases 100% smoke-free policies Aggressive media campaigns Cessation access Comprehensive ad restrictions
88
$0
$200
$400
$600
$800
$1,000
$1,200
1986 1987 1988 19891990 1991 1992 1993 19941995 1996 1997 19981999 2000 2001 2002 20032004 2005 2006 2007
Years
$ M
illio
ns
0
5
10
15
20
25
30
35
40
Pe
rce
nt
Cu
rre
nt
Sm
ok
ing
State Funding (adjusted to 2008) % High School Smoking
Source: Project ImpacTEEN; CDC/Office on Smoking and Health; Campaign for Tobacco Free Kids; Research Triangle Institute; University of Illinois at Chicago; University at Buffalo, State University of New York*High school students who smoked on 1 >/ of the 30 days preceding the survey--United States, CDC. Youth Risk Behavior Survey, 1993-2007.
Total Funding for State ProgramsAdjusted to FY2008 Dollars
99
State Status Toward Reaching CDC-Recommended Funding Levels —FY2009
AZ
WY
OR
ID
MT
UTNV
WA
CA
TX
AROK
ND
LA
KS
IANE
SD
CO
NM
MO
MN
TN
AL
KY
OH
MS
MI
IN
GA
FL
PA
ME
NY
WV VA
NC
SC
VT
CT
D.C.
RI
NJ
MD
DE
NHMA
IL
WI
AK
HI<20% (n=28)
40-59% (n=5)
60-79% (n=5)
>80% (n=1)
20-39% (n=12)
Source: CDC, Office on Smoking and Health.
Tobacco Industry is Outspending Prevention Efforts 20:1 -- 2007
StateTobaccoRevenue
(taxes and settlementfunds)
$22.3 billion
State Tobacco Program Budgets
$0.6 billion
Sources: Campaign for Tobacco Free Kids, American Heart Ass’n, American Cancer Soc., American Lung Ass’n, SmokeLess States National Tobacco Policy Initiative
Total CDC-Recommended Spending Level
$3.7 billion
Tobacco Industry
Marketing & Promotion
Expenditures$12.5 billion
1111
Cigarette Sales and Cigarette PricesUnited States, 1970-2007
Source: ImpacTeen Chartbook: Cigarette Smoking Prevalence and Polices in the 50 States.
12
State Cigarette Excise Tax Rates - 2006
AZ
WY
OR
ID
MT
UTNV
WA
CA
TX
AROK
ND
LA
KS
IANE
SD
CO
NM
MO
MN
TN
AL
KY
OH
MS
MI
IN
GA
FL
PA
ME
NY
WV VA
NC
SC
VT
CT
D.C.
RI
NJ
MD
DE
NHMA
IL
WI
AK
HI50-99 cents per pack
$1.00-$1.49 per pack
$1.50-$1.99 per pack
$2.00+ per pack
Source: CDC, Office on Smoking and Health. State Tobacco Activities Tracking and Evaluation (STATE) System.
<50 cents per pack
13
State Cigarette Excise Tax Rates - 2007
AZ
WY
OR
ID
MT
UTNV
WA
CA
TX
AROK
ND
LA
KS
IANE
SD
CO
NM
MO
MN
TN
AL
KY
OH
MS
MI
IN
GA
FL
PA
ME
NY
WV VA
NC
SC
VT
CT
D.C.
RI
NJ
MD
DE
NHMA
IL
WI
AK
HI50-99 cents per pack
$1.00-$1.49 per pack
$1.50-$1.99 per pack
$2.00+ per pack
Source: CDC, Office on Smoking and Health. State Tobacco Activities Tracking and Evaluation (STATE) System.
<50 cents per pack
14
State Cigarette Excise Tax Rates - 2008
AZ
WY
OR
ID
MT
UTNV
WA
CA
TX
AROK
ND
LA
KS
IANE
SD
CO
NM
MO
MN
TN
AL
KY
OH
MS
MI
IN
GA
FL
PA
ME
NY
WV VA
NC
SC
VT
CT
D.C.
RI
NJ
MD
DE
NHMA
IL
WI
AK
HI50-99 cents per pack
$1.00-$1.49 per pack
$1.50-$1.99 per pack
$2.00+ per pack
Source: CDC, Office on Smoking and Health. State Tobacco Activities Tracking and Evaluation (STATE) System.
<50 cents per pack
1515
State Cigarette Excise Tax Rates - 2009
AZ
WY
OR
ID
MT
UTNV
WA
CA
TX
AROK
ND
LA
KS
IANE
SD
CO
NM
MO
MN
TN
AL
KY
OH
MS
MI
IN
GA
FL
PA
ME
NY
WV VA
NC
SC
VT
D.C.
NJ
MD
DE
NHMA
IL
WI
AK
HI50-99 cents per pack
$1.00-$1.49 per pack
$1.50-$1.99 per pack
$2.00+ per pack
Source: CDC, Office on Smoking and Health. State Tobacco Activities Tracking and Evaluation (STATE) System.
<50 cents per pack
CT
RI
1616
State Cigarette Excise Tax Rates - 2009
AZ
WY
OR
ID
MT
UTNV
WA
CA
TX
AROK
ND
LA
KS
IANE
SD
CO
NM
MO
MN
TN
AL
KY
OH
MS
MI
IN
GA
FL
PA
ME
NY
WV VA
NC
SC
VT
D.C.
NJ
MD
DE
NHMA
IL
WI
AK
HI50-99 cents per pack
$1.00-$1.49 per pack
$1.50-$1.99 per pack
$2.00+ per pack
Source: CDC, Office on Smoking and Health. State Tobacco Activities Tracking and Evaluation (STATE) System.
<50 cents per pack
CT
RI $3.46
1717
State Cigarette Excise Tax Rates - 2009
AZ
WY
OR
ID
MT
UTNV
WA
CA
TX
AROK
ND
LA
KS
IANE
SD
CO
NM
MO
MN
TN
AL
KY
OH
MS
MI
IN
GA
FL
PA
ME
NY
WV VA
NC
SC
VT
D.C.
NJ
MD
DE
NHMA
IL
WI
AK
HI50-99 cents per pack
$1.00-$1.49 per pack
$1.50-$1.99 per pack
$2.00+ per pack
Source: CDC, Office on Smoking and Health. State Tobacco Activities Tracking and Evaluation (STATE) System.
<50 cents per pack
Chicago$3.66
NYC$4.25
CT
RI $3.46
1818
549
61
176
105
298
246
150
368
255
214040
20
77
2619.532.9
0
50
100
150
200
250
300
350
400
450
500
550
600
NY State Bars NY StateBowling Alleys
NY State PoolHall
NY StateBingo Hall
Norway PublicPlaces
Scotland Pubs Italy GameParlours
Italy Pubs Italy Outdoors
Pre-law Post-law
Indoor Air Quality Before and After Implementing a Smoke-Free Law
Source: Institute of Medicine. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Academies Press; 2009.
The outdoor ambient air quality standard for small particulate
matter (PM 2.5) is 35 µg/m3. There is no indoor standard.
PM
2.5
µ
g/m
3
35 µg/m3
1919
0
10
20
30
40
50
60
70
80
90
100
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Workplaces and/or Restaurants and/or Bars
Workplaces and Restaurants and Bars
Proportion of U.S. Population Covered by Local and State Smoke-Free Laws, 2000-2009
Population figures are as of December 31 of each given year, and October for 2009. All population figures are from the United States Census. Source: American Nonsmokers’ Rights Foundation.
Per
cen
t
100 million Americans continue to be exposed
State Smoke-Free Indoor Air Laws for Private Worksites, Restaurants, and Bars
AZ
WY
OR
ID
MT
UTNV
WA
CA
TX
AROK
ND
LA
KS
IANE
SD
CO
NM
MO
MN
TN
AL
KY
OH
MS
MI
IN
GA
FL
PA
ME
NY
WV VA
NC
SC
VT
CT
D.C.
RI
NJ
MD
DE
NHMA
IL
WI
AK
HI
N=51Source: Centers for Disease Control and Prevention. State Tobacco Activities Tracking and Evaluation (STATE) System. Available at: http://www.cdc.gov/tobacco/statesystem.
Ban in worksites, restaurants, and bars (n=22)
Ban in two of three locations (n=5)
No Ban in all these locations (n=24)
Laws in effect as of December 31, 2006
State Smoke-Free Indoor Air Laws for Private Worksites, Restaurants, and Bars
AZ
WY
OR
ID
MT
UTNV
WA
CA
TX
AROK
ND
LA
KS
IANE
SD
CO
NM
MO
MN
TN
AL
KY
OH
MS
MI
IN
GA
FL
PA
ME
NY
WV VA
NC
SC
VT
CT
D.C.
RI
NJ
MD
DE
NHMA
IL
WI
AK
HI
N=51Source: Centers for Disease Control and Prevention. State Tobacco Activities Tracking and Evaluation (STATE) System. Available at: http://www.cdc.gov/tobacco/statesystem.
Ban in worksites, restaurants, and bars (n=22)
Ban in two of three locations (n=5)
No Ban in all these locations (n=24)
Laws in effect as of December 31, 2007
State Smoke-Free Indoor Air Laws for Private Worksites, Restaurants, and Bars
AZ
WY
OR
ID
MT
UTNV
WA
CA
TX
AROK
ND
LA
KS
IANE
SD
CO
NM
MO
MN
TN
AL
KY
OH
MS
MI
IN
GA
FL
PA
ME
NY
WV VA
NC
SC
VT
CT
D.C.
RI
NJ
MD
DE
NHMA
IL
WI
AK
HI
N=51Source: Centers for Disease Control and Prevention. State Tobacco Activities Tracking and Evaluation (STATE) System. Available at: http://www.cdc.gov/tobacco/statesystem.
Ban in worksites, restaurants, and bars (n=22)
Ban in two of three locations (n=5)
No Ban in all these locations (n=24)
Laws in effect as of December 31, 2008
AZ
WY
OR
ID
MT
UTNV
WA
CA
TX
AROK
ND
LA
KS
IANE
SD
CO
NM
MO
MN
TN
AL
KY
OH
MS
MI
IN
GA
FL
PA
ME
NY
WV VA
NC
SC
VT
CT
D.C.
RI
NJ
MD
DE
NHMA
IL
WI
AK
HI
Ban in worksites, restaurants, and bars (n=22)
Ban in two of three locations (n=4)
Laws in effect as of December 31, 2009
N=51Source: Centers for Disease Control and Prevention. State Tobacco Activities Tracking and Evaluation (STATE) System. Available at: http://www.cdc.gov/tobacco/statesystem. *Enacted legislation is not yet effective in Kansas, Wisconsin.
No Ban in all these locations (n=25)
State Smoke-Free Indoor Air Laws for Private Worksites, Restaurants, and Bars
AZ
WY
OR
ID
MT
UTNV
WA
CA
TX
AROK
ND
LA
KS
IANE
SD
CO
NM
MO
MN
TN
AL
KY
OH
MS
MI
IN
GA
FL
PA
ME
NY
WV VA
NC
SC
VT
CT
D.C.
RI
NJ
MD
DE
NHMA
IL
WI
AK
HI
Ban in worksites, restaurants, and bars (n=23)
Ban in two of three locations (n=5)
Laws in effect as of May 1, 2010*
N=51Source: Centers for Disease Control and Prevention. State Tobacco Activities Tracking and Evaluation (STATE) System. Available at: http://www.cdc.gov/tobacco/statesystem. *Enacted legislation is not yet effective in Kansas, Wisconsin.
No Ban in all these locations (n=23)
State Smoke-Free Indoor Air Laws for Private Worksites, Restaurants, and Bars
State Smoke-Free Laws for Private Worksites, Restaurants, and Bars
AZ
WY
OR
ID
MT
UTNV
WA
CA
TX
AROK
ND
LA
KS
IANE
SD
CO
NM
MO
MN
TN
AL
KY
OH
MS
MI
IN
GA
FL
PA
ME
NY
WV VA
NC
SC
VT
CT
D.C.
RI
NJ
MD
DE
NHMA
IL
WI
AK
HI
Ban in worksites, restaurants, and bars (n=23)
Ban in two of three locations (n=5)
Laws in effect as of May 1, 2010*
N=51Source: Centers for Disease Control and Prevention. State Tobacco Activities Tracking and Evaluation (STATE) System. Available at: http://www.cdc.gov/tobacco/statesystem. *Enacted legislation is not yet effective in Kansas, Wisconsin.
No Ban in all these locations (n=23)
26
Aggressive Media Campaigns
Media campaigns Reduce youth initiation Encourage cessation Increase negative attitudes toward
tobacco use
27
The Impact of Cessation
Presently: 46 million U.S. smokers 70% of smokers want to quit 40% try to quit each year Only 2% call state or national quitlines
Tobacco cessation works best when combined with Significant tax and price increases Comprehensive smoke-free policies Advertising, promotion and sponsorship bans Aggressive counter-advertising
28
Quitline Counseling Alone or with Medication Significantly Increases 6-Month Abstinence Rates
8.5
12.7
28.1
0
10
20
30
Minimal Assistance Quitline Quitline and Medication
6-Month Quit Rate
Per
cen
t Q
uit
Source: Clinical Practice Guideline Meta-Analysis Results. Treating tobacco use and dependence: 2008 update. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service; 2008 May.
2929
Impact of Combined Interventions: Adult and Youth Smoking Prevalence in New York City
Sources: CDC. Decline in Smoking Prevalence -- New York City, 2002—2006. MMWR. 2007. 56(24);604-608; and New York City Department of Health and Mental Hygiene.
0
5
10
15
20
25
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Per
cen
t o
f ad
ult
s w
ho
sm
oke
3-yr. average 3-yr. average 3-yr. average
21.6% 21.5% 21.7% 21.6%
19.2%18.4% 18.9%
17.5% 16.9%15.8%
City and State tax increases
Smoke-freeworkplace TV ad
campaign
17.6%
14.8%
11.2%
8.5%
AdultYouth
0
10
20
30
40
50
60
70
80
1988 1990 1992 1994 1996 1998 2000 2002
Rat
e P
er 1
00,0
00
California
United States (minus California)
Poly. (United States (minusCalifornia))Poly. (California)
Lung and bronchus age-adjusted cancer incidence rates, 1988-2003
Rates are per 100,000 and age-adjusted to the 2000 U.S. standard (19 age groups).* The EAPC is significantly different from zero (p<0.05).Source: Cancer Surveillance Section. Prepared by: California Department of Health Services, Tobacco Control Section, 2007.
EAPC= -0.4*
EAPC= -1.4*
Lung and Bronchus Age-Adjusted Cancer Incidence rates, 1988-2003
15 year investment of $1.8 billion in tobacco control reduced health care costs by $86 billion
31
Opportunities Moving Forward
Family Smoking Prevention and Tobacco Control Act of 2009
On June 22, 2009, President Obama signed legislation granting the FDA the authority to regulate: CONTENT of tobacco products
MARKETING of tobacco products
SALES of tobacco products
FDA: Major Accomplishments To Date
August 2009
September 2009
January 2010
March 2010
March 2010
Established Center for Tobacco Products
Ban on Flavored Cigarettes
Industry Ingredient Submission Begins
Reissued 1996 Rule
First meeting of Tobacco Products Scientific Advisory Committee (TPSAC)
FDA’s Next Steps: Future Deadlines
June 2010
June 2010
June 2010
March 2011
June 2011
Ban on misleading terms (light, low, mild)
New Smokeless Warning Labels
1996 Rule takes effect
TPSAC Findings on Menthol
New Rules for Cigarette Warning Labels
Graphic Cigarette Warnings
FDA legislation mandates new graphic warnings must comprise the top 50% of the front and back of cigarette packs.
Rules must be issued no later than June 2011.
New warnings will take effect 15 months later.
Image Source: Health Canada
Roles for CDC in Tobacco Product Regulation
Technical assistance and guidance Laboratory (NCEH) General tobacco control (OSH)
Maintain comprehensive tobacco control programs
Coordinate national and state efforts
FDA will contract with states to aid in enforcement
Conduct post-marketing surveillance of effects of the tobacco product regulation
37
Michael A. TynanPublic Health AnalystCenters for Disease Control & Prevention Office on Smoking and Health
Ending the Tobacco Use Epidemic
The findings and conclusions in this presentation are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
